Mentor Application

Thank you for your interest to be a mentor for the HLNDV Mentoring Program. Please complete all fields and submit your resume for our committee to match you as quickly as possible. If you have any questions or concerns, please email careerdevelopment@hlndv.ache.net.

Are you a member in good standing of the American College of Healthcare Executives?

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* 1. Are you a member in good standing of the American College of Healthcare Executives?

First and Last Name

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* 2. First and Last Name

Current Job Title

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* 3. Current Job Title

Organization Name

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* 4. Organization Name

Preferred Phone Number

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* 5. Preferred Phone Number

Preferred Email Address

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* 6. Preferred Email Address

How many years of healthcare leadership experience do you have?

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* 7. How many years of healthcare leadership experience do you have?

Please select all areas you are able to provide guidance to a mentee.


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* 8. Please select all areas you are able to provide guidance to a mentee.


  Resume Review and/or Interview Preparation Hospital Management/Acute Care Leadership Long Term Care, Behavioral, Skilled Nursing Facility Leadership Ambulatory or Physician Practice Leadership Healthcare Consulting Managed Care Quality and Process Improvement Nursing, Medical or other Clinical Leadership
Mentor
Please select if you have a preference for working with a male or female mentee. (Select one option)

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* 9. Please select if you have a preference for working with a male or female mentee. (Select one option)

What level of experience do you look for in a mentee? (Check all that apply)

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* 10. What level of experience do you look for in a mentee? (Check all that apply)

What preference do you have for current roles in a mentee? (Check all that apply)

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* 11. What preference do you have for current roles in a mentee? (Check all that apply)

What characteristics do you look for in a mentee? (Check all that apply)

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* 12. What characteristics do you look for in a mentee? (Check all that apply)

Upload resume here (required)

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* 13. Upload resume here (required)

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